analysis) and reviewing limitations imposed on the current system that interfere with the efficient use of existing resources.

The national health target recommended in Chapter 1 is an ambitious one, but the committee believes that it is achievable because much of the current morbidity and mortality is preventable—half the deaths in the United States and more than half the morbidity (perhaps three-fourths) (CDC, 2005; Danaei et al., 2009; IOM, 2008; Woolf et al., 2007, 2010). The cost of the preventable disease burden makes it crucially important to seek, find, and implement solutions. According to federal estimates, “one year’s worth of injuries has an estimated lifetime cost of $406 billion in medical expenses and lost productivity” (Foreman, 2009). In 2004, total Medicaid smoking-attributable expenditures amounted to $22 billion (Armour et al., 2009).

The core mission and unique competence of the governmental public health agencies (public health departments) are informed by their focus on wellness and prevention rather than illness care and treatment. Public health departments are statutorily charged with protecting and promoting population health, and they are uniquely positioned and qualified (through the science, tools, and skills of public health, including epidemiology and health planning) to take or support evidence-based action on many of the risk factors that lead to poor health. Although some clinical care interventions can help to prevent a disease process in an individual, they cannot be used efficiently throughout a population to address pressing community health challenges. Those challenges, such as growing rates of obesity and diabetes, increase health care costs, diminish American productivity and competitiveness, and probably limit the opportunities available to the next generation of Americans because of increasingly poor health. Taking action as early and at the level of population, long before diabetes is diagnosed in one obese person, or chronic bronchitis4 is diagnosed in one smoker, is the most efficient and effective route to disease prevention.

The nation needs to rely on public health departments to lead the effort to reduce the burden of preventable morbidity and mortality. It is important to consider why public health has not already done more in this regard. A large part of the answer is that only a small proportion of current public health financing targets the major causes of preventable morbidity and mortality in the 21st century. Partly as a result of the historic successes of public health against infectious diseases, today’s preventable disease burden is primarily the result of chronic disease, injury, and upstream social determinants. Although it is essential to ensure that funding continues to sustain hard-won public health achievements in maternal and child health, environmental sanitation and hygiene, and the prevention of infectious diseases, public health investments are needed to address the full array of high-

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4A precursor of and part of chronic obstructive pulmonary disease.



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